I continue to get questions about billing for anticoagulation management, and I’m hoping this post can put some (all?) of them to rest.
First, codes deleted in 2018. CPT® had two codes for this service, 99363 and 99364 that had a bundled status indicator from Medicare, meaning they weren’t paid by Medicare or most insurance companies. They’re gone.
Currently, there are two sets of codes, three HCPCS codes and two CPT® codes. They aren’t defined exactly the same, and so take careful reading. The HCPCS codes relate only to home INR monitoring, while one of the CPT® codes can be used when the test is done in the home, office or lab.
Home INR testing, and management of home INR test results
In 2018, we got two new codes. You can read about 93972 and 93973 in more detail later in this post.
93792 is for patient/caregiver education for initiation of home international normalized ratio (INR) testing. The patient obtains the equipment from a DME provider to test their own blood at home, and prior to doing the testing, a staff member has a face-to-face educational session with the patient, showing them how to collect the sample and test their blood, and documenting their ability to perform the tests and report the results. That service has 0 wRVUs because it is staff work.
The second code released in 2018, 93973, was for non-face-to-face review of INR results and management. It is for reviewing the results of an INR done at home, at the office or in a lab. The national payment amounts for each service are listed in the linked article.
Can a staff member do the management described by 93973?
I got asked that question, did some research and answered, “I think so.” You can read the answer for yourself at the end of this page. I wish I could be more definitive.
Now, to the older, HCPCS codes that relate only to home INR services.
HCPCS codes, G0248, G0249, G0250
G0248 Demonstration, prior to initiation of home inr monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the inr monitor, obtaining at least one blood sample, provision of instructions for reporting home inr test results, and documentation of patient’s ability to perform testing and report results
G0249: Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week
G0250: Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week
These three codes are longstanding codes with a status indicator in the Medicare fee schedule of R, restricted. This is defined as Contractor priced, although there are RVUs in the fee schedule. They were not deleted with the addition of the CPT® codes.
G0248 is similar to the new CPT® code 93972. Both require in person education, obtaining one sample, instructions for reporting and an assessment of how well the patient will be able to perform the test and report the results.
G0249 includes providing the machine and materials for INR testing. This is not a DME benefit but is a paid under the physician fee schedule. The practice provides the machine that the patient uses to test their blood.
G0250 requires “face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring.” The frequency of the face-to-face verification is not listed in the code.
G0250 and 93793 are similar but with a key difference:
The difference is where the lab test was done. Use of code G0250 is not more than once a week, and is only used for home testing of INR. 93793 is used for review and management of a new test done at home, in the office or in the lab. 93793 specifically requires providing patient instructions, dosage adjustment, if needed, and scheduling additional tests, when needed. 93793 is used in more situations. It allows billing non-face-to-face assessment and management of INR tests done at home, in the office or at a lab, but it also has more specific requirements for patient instructions and management.
If your practice has been reporting these HCPCS codes, compare the descriptions of the HCPCS codes and CPT® codes carefully, and the payment from your Contractor. For non-Medicare patients, use the CPT® codes. You can read more about the requirements for the HCPCS codes in Chapter 32 of the Medicare Claims Processing Manual.
Nurse visits and INR
The services above are for teaching the patient how to do a home INR (G0248, 93792), providing the INR machine and materials (G0249) and monitoring and dosage adjustment, based on the patient’s results. (G0250–home, 93793—home, office, lab)
But, not all patients want to or can test their own blood at home. Some patients have the test done at their medical practice, and these do not always fall on the day of an office visit. If the patient has the service done on the same day as an office visit, bill the office visit done by the physician/NP/PA and bill the PTINR, 86510. For CLIA waived tests, add modifier QW. The CPT® code for a fingerstick, 36416, has a status indicator of bundled, and Medicare won’t pay it, and neither will most payers. Do not bill either a nurse visit or code 93793 when done on the day of an office visit.
If a patient presents to have her PTINR checked, the lab test is performed and the nurse provides the management advice about the dosage of warfarin, that may be billed as a nurse visit, in addition to the lab test. The nurse must be providing the treatment advice face-to-face with the patient, either in consultation with the physician/NP/PA or based on a scale developed by the practitioner. Remember if it is a Medicare patient, you must meet incident to guidelines.
Nurse visit or 93793?
That depends on whether the work is done in person or not. And, neither 93793 or a nurse visit may be performed on the day of another E/M service.
Anticoagulation management and education for home INR monitoring
CPT developed (and Medicare recognizes) two new codes for services related to home and outpatient international normalized ratio (INR) monitoring services in 2018.
Here are the new codes | CPT® 93792, 93793
93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified healthcare professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient’s/ caregiver’s ability to perform testing and report results
93793 Anticoagulation management for patients taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR)test results, patient instructions, dosage adjustment (as needed), and scheduling of additional test (s), when performed
Both have a status indicator of “A”.
|Code||Brief description||2020 Work RVU||National non-facility payment||National facility payment|
|93792||Pt/caregiver train home inr||0.00||$66.40||$65.32|
|93793||Anticoag mgmt pt warfarin||0.18||$11.91||$11.91|
There’re a few remarkable things about this.
First, it continues Medicare’s support for primary care. This monitoring is typically done by either primary care or cardiology and up till now, was considered part of the pre-and post-work for an office visit. Although there were CPT® codes for anticoagulation management, they had a status indicator of bundle and were not reimbursed by any payers.
Second, although the payment is low particularly for the management in response to the INR test, some practices perform this service frequently. It is payment for work that is already being done.
93792 is the code used for patients who test their INR at home, rather than going to the laboratory. Prior to starting this home testing, the patient needs to understand how do use the test reliably. This instruction and training is now covered service. Notice that for patient/caregiver instruction and training, there are no work RVUs assigned. This is work that would typically be done by clinical staff or case managers.
93793 Is payment for managing patients taking warfarin. It includes the review and interpretation of a new lab test done in the home, office or lab. This code does have work RVUs, recognizing that it is physician/NP/PA work to interpret the lab results, make a dosing adjustment if needed, and schedule additional tests, again if needed. The dosage does not need to be changed in order to report 93793. It is for a new test result.
Can these be performed on the same day as an E/M service?
CPT® says that a separately identifiable E/M service may be reported on the same day as 93792, instructions and training for a patient who will start home INR monitoring.
“Do not report 93793 on the same day as an E/M service.”
So, if the INR is done on the day of the visit and the physician/NP/PA interprets the result and gives the patient dosage instructions, do not report 93793 in addition to the E/M.
CPT® also states not to report either code during the service time of chronic care management (CCM) or transitional care management (TCM). (99487, 99489, 99490, 99495, 99496) During the service period would mean during any calendar month of reporting CCM and during the 30-day post discharge period if billing TCM.
This is good news. It is payment for services medical groups are already doing.
Can we bill for RN services?
My question is regarding Anticoagulation Management Code 93793. Guidelines state that this code can be performed by a physician, NP, or PA. My question is, if clinical staff performs the service in the doctor’s office setting, can code 93793 be billed under the supervising physician’s name?
- Sees the patient face to face
- Queries the patient regarding any unexplained bleeding, bruising, changes in diet, any other interacting medication usage, etc.,
- Obtains the PT INR
- Reviews the results
- Changes dose or keeps the same dose according to an AMS flowsheet
- Arranges future appointments
- CLINICAL STAFF routes the note to the physician
Can this code be billed under the physician’s name when performed by clinical staff in the doctor’s office setting? If so, would there have to be an attestation and/or co-signature by the physician?
This code does not require a face-to-face service, but there is nothing in the description that precludes it being performed face-to-face. It may not be done on the day of an E/M service, and check the CPT® book for other “do not report” with codes, which include chronic care management and TCM.
The CPT® Changes Insiders’s View 2018, in the description of the procedure specifically does not say if it must be done by the provider or by the clinical staff.
In my opinion, you can bill this under the physician’s provider number for work done by the clinical staff. I think sign off would be a could work process, but I don’t have a citation for this.
Watch Betsy’s 60 minute on-demand webinar “Care Management in Primary Care Practices” for a review of the coding rules as well as tips for doing, and documenting care management services. Webinars are free for members.
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